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. 2022 Jan 18;2(1):73-84.
doi: 10.1016/j.jacasi.2021.10.012. eCollection 2022 Feb.

Prognostic Impact of Echocardiographic Congestion Grade in HFpEF With and Without Atrial Fibrillation

Haruhiko Abe  1 , Shumpei Kosugi  1 , Tatsuhisa Ozaki  1 , Tsuyoshi Mishima  1 , Motoo Date  1 , Yasunori Ueda  1 , Masaaki Uematsu  1 , Shunsuke Tamaki  2 , Masamichi Yano  3 , Takaharu Hayashi  4 , Akito Nakagawa  5   6 , Yusuke Nakagawa  7 , Takahisa Yamada  2 , Yoshio Yasumura  5 , Tomoharu Dohi  8 , Shinichiro Suna  8 , Shungo Hikoso  8 , Daisaku Nakatani  8 , Yukihiro Koretsune  1 , Yasushi Sakata  8
Affiliations

Prognostic Impact of Echocardiographic Congestion Grade in HFpEF With and Without Atrial Fibrillation

Haruhiko Abe et al. JACC Asia. .

Abstract

Background: Atrial fibrillation (AF) is common in heart failure with preserved ejection fraction (HFpEF).

Objectives: This study aimed to investigate the prognostic value of echocardiographic markers of congestion that can be applied to both AF and patients without AF with HFpEF.

Methods: We conducted a multicenter study of 505 patients with HFpEF admitted to hospitals for acute decompensated heart failure. The ratio of early diastolic transmitral flow velocity to mitral annulus velocity (E/e'), the tricuspid regurgitation peak velocity, and the collapsibility of the inferior vena cava were obtained at discharge. Congestion was determined by echocardiography if any one of E/e' ≥14 (E/e' ≥11 for AF), tricuspid regurgitation peak velocity ≥2.8 m/s, or inferior vena cava collapsibility <50% was positive. We classified patients into grade A, grade B, and grade C according to the number of positive congestion indices. The primary endpoint was the composite of cardiovascular death and heart failure hospitalization.

Results: During the follow-up period (median: 373 days), 162 (32%) patients experienced the primary endpoint. Grade C patients had a higher risk for the primary endpoint than grade A (HR: 2.98; 95% CI: 1.97-4.52) and grade B patients (HR: 1.92; 95% CI: 1.29-2.86) (log-rank P < 0.0001). Echocardiographic congestion grade improved the predictive value when added to the age, sex, New York Heart Association functional class, and N-terminal pro-B-type natriuretic peptide, not only in sinus rhythm (Uno C-statistic: 0.670 vs 0.655) but in AF (Uno C-statistic: 0.667 vs 0.639).

Conclusions: Echocardiographic congestion grade has prognostic value in patients with HFpEF with and without AF.

Keywords: AF, atrial fibrillation; ASE, American Society of Echocardiography; E/e′, ratio of early diastolic transmitral flow velocity to mitral annulus velocity; EACVI, European Association of Cardiovascular Imaging; HFpEF, heart failure with preserved ejection fraction; IVC, inferior vena cava; IVCC, inferior vena cava collapsibility; NT-proBNP, N-terminal pro–B-type natriuretic peptide; NYHA, New York Heart Association; TRV, tricuspid regurgitation peak velocity; congestion; echocardiography; heart failure with preserved ejection fraction; prognosis.

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Conflict of interest statement

This work was funded by Roche Diagnostics K.K. and Fuji Film Toyama Chemical Co. Ltd. Dr Abe has received grants from Boehringer Ingelheim Japan. Dr Hikoso has received personal fees from Daiichi Sankyo Company, Bayer, Astellas Pharma, Pfizer Pharmaceuticals, and Boehringer Ingelheim Japan and has received grants from Roche Diagnostics, Fujifilm Toyama Chemical, and Actelion Pharmaceuticals. Dr Nakatani has received honoraria from Roche Diagnostics. Dr Koretsune has received personal fees from Daiichi Sankyo Company. Dr Sakata has received personal fees from Otsuka Pharmaceutical, Ono Pharmaceutical, Daiichi Sankyo Company, Mitsubishi Tanabe Pharma Corporation, and Actelion Pharmaceuticals and has received grants from Roche Diagnostic, Fujifilm Toyama Chemical, Abbott Medical Japan, Otsuka Pharmaceutical, Daiichi Sankyo Company, Mitsubishi Tanabe Pharma Corporation, and Biotronik. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

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Graphical abstract
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Graphical abstract
Figure 1
Figure 1
Flowchart of the Study Population ADHF = acute decompensated heart failure; HFpEF = heart failure with preserved ejection fraction.
Central Illustration
Central Illustration
Prognostic Impact of Left- and Right-Sided Echocardiographic Congestion Grade As shown in the flow chart, echocardiographic congestion grade was determined by the number of positive findings using different criteria for averaged E/e′ in sinus rhythm and AF. Echocardiographic congestion grade was determined for patients for whom at least 1 of the 3 indices was obtained. Only positive indices were used in the flowchart, and indices that could not be obtained were considered negative. Echocardiographic congestion grade was classified into grade A (no congestion), grade B (1 index was positive), and grade C (2 or 3 indices were positive) at discharge. The Kaplan-Meier curves for cardiovascular mortality and heart failure hospitalization among the 3 echocardiographic congestion grades were shown. Echocardiographic congestion grade improved the predictive value when added to age, sex, New York Heart Association functional class, and N-terminal pro–B-type natriuretic peptide, not only in sinus rhythm but also in AF. AF = atrial fibrillation; E/e′ = the ratio of early transmitral flow peak velocity to early diastolic peak velocity of the mitral annular plane; HF = heart failure.
Central Illustration
Central Illustration
Prognostic Impact of Left- and Right-Sided Echocardiographic Congestion Grade As shown in the flow chart, echocardiographic congestion grade was determined by the number of positive findings using different criteria for averaged E/e′ in sinus rhythm and AF. Echocardiographic congestion grade was determined for patients for whom at least 1 of the 3 indices was obtained. Only positive indices were used in the flowchart, and indices that could not be obtained were considered negative. Echocardiographic congestion grade was classified into grade A (no congestion), grade B (1 index was positive), and grade C (2 or 3 indices were positive) at discharge. The Kaplan-Meier curves for cardiovascular mortality and heart failure hospitalization among the 3 echocardiographic congestion grades were shown. Echocardiographic congestion grade improved the predictive value when added to age, sex, New York Heart Association functional class, and N-terminal pro–B-type natriuretic peptide, not only in sinus rhythm but also in AF. AF = atrial fibrillation; E/e′ = the ratio of early transmitral flow peak velocity to early diastolic peak velocity of the mitral annular plane; HF = heart failure.
Figure 2
Figure 2
Interrelationship Between E/e′, TRV, and IVCC Among Patients With Heart Failure With Preserved Ejection Fraction Even after decongestion therapy, 27% of patients showed grade C echocardiographic congestion. E/e′ = the ratio of early transmitral flow peak velocity to early diastolic peak velocity of the mitral annular plane; IVCC = inferior vena cava collapsibility; TRV = tricuspid regurgitation peak velocity.
Figure 3
Figure 3
Event-Free Probability in Patients With Heart Failure With Preserved Ejection Fraction The Kaplan-Meier curves for cardiovascular mortality and heart failure hospitalization among the 3 echocardiographic congestion grades are shown. Grade C echocardiographic congestion showed poor prognosis in patients with heart failure with preserved ejection fraction.
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